New York State Home
New York Liquidation Bureau
Maria T. Vullo
Superintendent as Receiver
 
Form Sections:
  1. Reporter Information
  2.  
  3. Type of Misconduct
  4.  
  5. General Information
  6.  
  7. Detailed Report
Form to Report Fraud/Misconduct
1. Reporter Information
Section 1 items OPTIONAL.  Your name will be kept strictly confidential.
(It is important to provide a way to contact you.)

2. Type of Misconduct
Please make only one selection per form.
Information concerns: Insurance Fraud  Vendor  Employee

Other – 

3. General Information
If you need more space, please add additional information in section 4.




4. Detailed Report
Describe exactly what incident you would like us to be aware of.  Please be as specific as possible.   Include names, dates, times and places.  Also let us know who we should talk to in order to get further information or where we might locate evidence.



     
Top